February 21, 2013 – The Departments of Health and Human Services, Labor and Treasury have jointly released yesterday a Final Rule which contained clarification as to how self-insured plans are to comply with the ACA’s cost-sharing limitations and how self-insured plans are to calculate Minimum Plan Value. The Rule also detailed how the Essential Health Benefits (EHBs) will be determined as well as how self-insured plans are to comply with requirements which are linked with such benefits.

Cost-Sharing Limitations

The Final Rule codifies that self-insured plans do in fact need to comply with the limitations on cost-sharing under the new law. Specifically, the amounts required to be paid under a self-insured plan in the form of cost-sharing (e.g., deductibles, co-pays, and other co-insurance) cannot exceed the maximum out-of-pocket limits for a high-deductible health plan defined under the health savings account (“HSA”) rules for 2014.

The Final Rule makes mention of the concerns of the timing and operational issues that are associated with such a restriction. As such, concurrent sub-regulatory guidance will be issued identifying an enforcement safe harbor for self-insured group health plans to address those operational concerns.

Through this Rule, the agencies confirmed that self-insured plans are not required to comply with the annual deductible limitations that are otherwise applicable to fully-insured health plans purchased by a small employer (i.e., under the new law, fully-insured “small group” health plans cannot include a deductible greater than $2,000 for single coverage and $4,000 for family coverage).

Determining Minimum Value

The Final Rule clarifies how self-insured plans are to calculate whether they meet a Minimum Plan Value threshold. An employer-sponsored plan provides Minimum Value if the employer’s share of the total allowed costs of benefits provided under the plan is greater than 60 percent. To calculate Minimum Value, employer-sponsored plans may account for any benefits covered by the employer that are also covered in any one of the EHB-benchmark plan options in any State. Employer contributions to an HSA and amounts newly made available under an “integrated’ HRA will be taken into account in determining Minimum Value.

Minimum Plan Value can be determined through any of the following options:

The Minimum Value Calculator made available by the Department of Health and Human Services and the Internal Revenue Service

Any safe harbor established by the Departments of Health and Human Services and the Internal Revenue Service

Certification by an actuary to determine MV if the plan contains non-standard features that are not suitable for either of the methods

For further details about the Rule’s specific provisions or for help with interpretation, please contact Jay Fahrer, SIIA’s Director of Government Relations at 202-463-8161 or jfahrer@siia.org.

This has been another real-time, exclusive ACA implementation report brought to you by SIIA’s government relations team. Additional informational content will be provided at the association’s upcoming Self-Insured Health Plan Executive Forum (March 20-21, 2013) and Legislative/Regulatory Conference (April 17-18, 2013). Detailed event information can be accessed on-line at www.siia.org.